Healthcare Provider Details

I. General information

NPI: 1841615556
Provider Name (Legal Business Name): LESLIE LYTLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 SW MAPLE ST.
DALLAS OR
97338
US

IV. Provider business mailing address

1020 SW MAPLE ST
DALLAS OR
97338-2129
US

V. Phone/Fax

Practice location:
  • Phone: 971-241-5881
  • Fax:
Mailing address:
  • Phone: 971-241-5881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: